Chapter 2: Work Planning and Control

f
Job Safety Analysis Form
Product ID: 513 | Revision ID: 2335 | Date Published: 44326.29 | Date Effective: 44326.29
ENVIRONMENT, SAFETY & HEALTH DIVISION URL: https://www-group.slac.stanford.edu/esh/eshmanual/references/wpcFormJSA.pdf | docx

This form is used to document the job safety analysis (JSA) required for the authorization and release of non-resident yellow, red, and construction work. Note red and construction work requires final
release through a tailgate briefing. Approved forms are to be kept in the work package; work packages are to be kept for 90 days after completion of the work, yellow by the authorizing supervisor;
red and construction by the project manager or field construction manager (FCM)/service manager (SM). (See Work Planning and Control: Work Planning and Control Procedure [SLAC-I-720-0A21C-
002] and Work Planning and Control: Construction Work Planning and Control Procedure [SLAC-I-720-0A21C-005].)

Job / Activity: JSA # (optional): Start Date: Valid Through:

Department / Group / Subcontractor: Bldg / Area Location(s): Type of Work: Other Information or References:
yellow, resident red
yellow, non-resident construction
Scope of Work ( attached):

Step Number Step Hazard Control

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

44326.29 SLAC-I-730-0A21J-034-R2 Final v2 1 of 2

SLAC National Accelerator Laboratory | Environment, Safety & Health Division Work Planning and Control | Job Safety Analysis Form

Acknowledgement (worker): I understand and will adhere to the steps, hazards, and controls in this JSA. I understand that performing steps out of sequence may pose hazards that have not been
evaluated nor authorized. I will contact the person who authorized my work prior to continuing, if the scope of work changes or new hazards are introduced. I understand my stop work authority
and responsibility.
Name (print): Signature: Date
Name (print): Signature: Date:
Name (print): Signature: Date:
Name (print): Signature: Date:
Name (print): Signature: Date:
Name (print): Signature: Date:
Name (print): Signature: Date:
Name (print): Signature: Date:
Name (print): Signature: Date:
Name (print): Signature: Date:

Approval (general subcontractor’s representative, required for construction work): I have reviewed and approve the work indicated in this JSA.
Name (print): Signature: Date:
Review (ESH representative, if requested): I have reviewed this JSA.
Name (print): Signature: Date:
Authorization (supervisor administrative functional; foreman for subcontractor work): I have reviewed the steps, hazards and controls described in this JSA with all workers listed above
and authorize them to perform the work. Workers are qualified (that is, licensed or certified, as appropriate, and in full compliance with training requirements) to perform this activity.
Name (print): Signature: Date:
Confirmation ( FCM SM POC, required for subcontractor work): I have confirmed that this JSA has been properly developed, reviewed, and approved.
Name (print): Signature: Date:
Release ( area manager building manager FCM SM POC): I have communicated unique area hazards, boundary conditions, and so on with the authorizer and/or listed worker(s)
and have coordinated this job with affected occupants. Listed workers are released to perform described scope of work. (If work is red or construction, document final release with tailgate meeting,
and also an WIP for red work.)
Boundary conditions, notes ( attached):

Name (print): Signature: Date:

44326.29 SLAC-I-730-0A21J-034-R2 Final v2 2 of 2